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NPI Code Detail

MEDICARE: AUNT MARTHAS

MEDICARE: AUNT MARTHAS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261Q00000XClinic/CenterIL

General Provider Information

NPI Number : 1912030305
Entity Type Code : Organization
Provider Name (Legal Business Name) : AUNT MARTHAS
Provider Business Mailing Address
First Line : 1536 VINCENNES AVE
Second Line :
City : CHICAGO HEIGHTS
State : IL
Zip : 60411-3458
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1536 VINCENNES AVE
Second Line :
City : CHICAGO HEIGHTS
State : IL
Zip : 60411-3458
Country : US
Telephone Number : 708-756-1134
Fax Number :
Authorized Official
Title or Position : FAMILY PHYSICIAN
Name : SUSHMA M RAGHAVENDRA
Credential : MD
Telephone Number : 708-756-1135
Provider Enumeration Date : 03/14/2007
Last Update Date : 08/22/2020

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Directions to “AUNT MARTHAS ” Practice Location

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